Archived: Begbrook House Care Home

Updated 26 January 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place 13 December 2016 and was unannounced. The inspection was undertaken by two inspectors and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

We reviewed the information that we had about the service including statutory notifications. Notifications are information about specific important events the service is legally required to send to us.

Some people who used the service were able to tell us of their experience of living in the home. For those who were unable we made detailed observations of their interactions with staff in communal areas.

We spoke with 10 people that used the service, six relatives, six members of staff and two visiting health professionals. We also spoke with the registered and regional manager.

We reviewed the care plans and associated records of six people who used the service. We reviewed the medicines administration records (MAR’s) of the people who lived at the home. We reviewed documents in relation to the quality and safety of the service, staff recruitment, training and supervision.

Updated 26 January 2017

This inspection took place on 13 December 2016 and was unannounced. Since the previous inspection conducted in November 2015 the registration status of the service has changed to a new legal entity, but has remained with the same provider organisation.

Begbrook House Care Home is registered to provide personal or nursing care for up to 32 people. At the time of our inspection there were 30 people living in the service.

There was a registered manager in place on the day of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People's records were not always completed consistently or correctly to monitor and manage their health conditions. Some people were having their food and fluid intake monitored because they had been assessed as being at risk of dehydration or malnutrition. Their food and fluid charts were not adequately completed.

The service was not consistently responsive to people’s needs. The quality and content of care plans was variable. People were not consistently involved in the decision making process regarding their care plans or in the reviews.

People told us that the staff were kind, caring and respectful. Concerns were expressed regarding the communication levels of some staff where English was not their first language. Staff were knowledgeable about people’s needs and were aware of their life histories and background. Staff told us how people preferred to be cared for and demonstrated they understood the people they cared for. Staff felt well supported by the deputy and registered manager.

Care plans contained risk assessments. These included risk assessments for falls, moving and handling, skin integrity and bed rails. The assessments had been reviewed monthly and when risks to people had been identified, there were generally comprehensive plans in for place for staff to follow in order to reduce the risks.

Records showed that a range of checks had been carried out on staff to determine their suitability for work. Staffing levels were maintained in accordance with the assessed dependency needs of the people who used the service. Staff demonstrated a good awareness and understood their responsibilities with regard to safeguarding people from abuse.

People's rights were in the main being upheld in line with the Mental Capacity Act (MCA) 2005. This is a legal framework to protect people who are unable to make certain decisions themselves. In people's support plans we saw information about their mental capacity and Deprivation of Liberty Safeguards (DoLS) being applied for. These safeguards aim to protect people living in care homes from being inappropriately deprived of their liberty.

People spoke positively about the activities offered and told us the programme was varied and enjoyable. Relatives were welcomed to the service and could visit people at times that were convenient to them.

People and their relatives spoke highly of the deputy and registered manager. They found them to be very helpful and approachable. They acknowledged that they had made improvements to the service in the short time they had been in post. They felt the atmosphere at the service had improved and described it as a happy friendly place. A recent external report by a health professional team stated; 'At present the new home manager is making excellent progress. Her leadership is palpable and the staff are responding to her style and consistency.'

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.